Document 13583883


College Credit Plus

Science Experience Internship

Last Name____________________________ First Name ______________________________

Cell Phone (______) ____________________ Home Phone (______) _____________________

Email Address __________________________________

High School Name ______________________________

Current HS Grade Level: Freshman _____Sophomore ______Junior ______Senior _______

Expected High School Graduation Date: ________________

Intended College Major ________________________________________Undecided ________

Have you participated in any extracurricular programs involving math-science-technology activities, such as a science camp or robotics team? If so, please describe below.

Students applying for a Science Experience Internship should indicate a desired area of study to assist with placement. Placement is determined by a student’s indicated research interest and availability of participating faculty advisors.

Please indicate area(s) of research interest for

Science Internship placement. If you have more than one area of interest, please indicate preference using numbers 1-6.

______ Biology

______ Chemistry

______ Computer Science

______ Geology

______ Physics

______ Psychology

Personal Information (for reporting purposes only):

Gender: ________________


__Hispanic or Latino

__Not Hispanic or Latino

Race (may choose more than one)

__American Indian or Alaska Native


__Black or African American

__Native Hawaiian or Other Pacific Islander